The IOPC is a super committee of AACN, NAN, D40, and ABN, tasked with coordinating advocacy efforts and improving the practice climate for Neuropsychology. The Healthcare Reform Toolkit is an evolving interactive website designed to educate neuropsychologists about healthcare reform and share effective practice models

Innovative practice models

As healthcare reform moves forward in each state, neuropsychologists and psychologists are developing innovative practice models in order to emerge as successful players. While much of the information on healthcare reform is abstract, hearing first hand about how practitioners are transforming their practice in response to healthcare reform gives us all very concrete examples of directions to take in our own practices. What changes are early adapters making? What tips can they offer us as we make changes?

We will post interviews with psychologists and neuropsychologists who are successfully adapting to this new healthcare environment, with the hopes that other clinicians will replicate and build on their success.

Dr. Goldberg has transformed his large multi specialty group practice operating in a traditional fee for service paradigm into a model of psychological service delivery in the context of healthcare reform. Dr. Goldberg has been a long time advocate for access to neuropsychological services in his role as Past President of the Massachusetts Psychological Association, and current associate member of the Massachusetts Neuropsychological Society.

Dr. Goldberg, you are well
known in the state of Massachusetts for your innovative practice model.
Can you tell us about what your practice looked like, prior to healthcare
reform?

What did you see as the
dangers to traditional psychology practice, as a result of healthcare reform
and the ACO structure/ global payment model?

"Traditional" psychology
practice is difficult to define. However, it is clear that the ability to
practice independent of larger systems of healthcare will become increasingly
more difficult as the country moves away from the fee for service system of
care toward global payment systems.

Can you tell us what your practice
looks like now? What are the major changes you made in response to the
changing healthcare climate?

Our practice was well equipped to
weather the storm of changes blowing through now. We have always
delivered comprehensive multi-modal and interdisciplinary services. The
biggest changes we have made relate to developing formal agreements with
primary care and specialty care entities to integrate services with the goals
of increasing efficiencies and controlling costs while improving access to
effective behavioral health services.

Can you tell us about the
neuropsychologists in your practice. Is there a difference in the way
neuropsychology services are delivered?

Neuropsychology continues to be
practiced with the same core principles and goals. While there have been
some changes already there will continue to be significant changes in how neuropsychology
is practiced in the next 3-5 years. These changes can be summarized as
follows:

Being able to provide services for the full breadth of patients seen.

Using technology and technicians to increase efficiency.

Crafting reports based more on the needs healthcare providers.

Completing reports in a timeframe that corresponds to the clinical needs of the patient.

Moving away from a "diagnosis and adios" model of freestanding assessment to a model of assessment plus ongoing consultation.

As a group practice we are able to meet
the overall needs of primary care practices while allowing individual
neuropsychologists that ability to maintain expertise in particular areas of
interests.

How do global or bundled
payments effect neuropsychology billing in your practice?

The movement toward integrated care,
which demands comprehensive services, has resulted in a very significant
increase in the demand for all behavioral health services, including
neuropsychology, in our practice. However, I am confident that as
transition to the primary care entities taking on financial risk for healthcare
continues, neuropsychology will be evaluated more in terms of its
clinical utility as defined by physicians and its "return on
investment" in helping to control healthcare costs while improving
clinical outcomes.

When you speak with healthcare
executives about behavioral health services, is neuropsychological assessment
on their radar screen?

The good news is that frontline
healthcare providers continue to demand neuropsychological services. However,
health plan executives and healthcare group executives do not seem to value or
demand neuropsychology services per se. They want us to assess, treat
and manage the overall behavioral health needs of the patient. To the extent we
use neuropsychology to do that effectively and efficiently neuropsychology will
thrive.

What is your advice to
practitioners as healthcare reform hits their states?

In addition to what I have already
discussed, it’s important for practitioners to understand how global payment
systems work and the needs and opportunities that the systems create for neuropsychologists. I would also recommend that
practitioners become part of a system of healthcare.

Dr. Bourne runs the behavioral health program at Atrius Healthcare. In her interview, she shares strategies for speaking with healthcare executives about being included in ACO networks as well as strategies for integrating neuropsychology services in to primary care. Her interview will be posted shortly.

1. Leslie, can you tell us about your role in Reliant Medical Group?

Reliant is a large multi specialty, multi site medical practice. I am the Chief of Behavioral Medicine, and involved in a number of areas within the organization. Typically, referrals come to Behavioral Health through primary care and other physicians. We work with “health psychology” issues including weight loss, chronic pain, sleep issues, and diabetes management. We also see typical cases of depression and anxiety.

Our psychologists also go directly to primary care offices and co-lead group medical visits. These are innovative sessions with 6-12 patients, co led by a PCP and psychologist, addressing a common health concern. For example, it might be a follow up visit for patients with chronic pain conditions, or diabetes. The psychologist will facilitate the group process.

2. Are these group medical visits unique to Reliant?

No, these occur commonly in the Medical Home model. For example, Harvard Vangaurd is running sessions like these. With global payments, physicians have the latitude to create these types of innovative visits, without limitations involved with traditional billing.

Hmm. This sounds like something neuropsychologists might be able to do, co-leading group follow ups for memory problems, or mTBI….

3. Do you have neuropsychologists in your Behavioral Medicine Group?

Not at this time. Right now we have 4 psychologists and one psychiatrist.

4. How do the finances work for billing your services in the medical home model?

It’s complicated! There are a number of payment arrangements. Most of Reliant’s revenue comes from capitated contracts, when we bill there is an internal transfer of funds credited to our department. Fee for service revenue flows through as actual net collected fees. Reliant is one of 6 medical groups within Atrius Health Care, which is one of the 33 Pioneer Accountable Care Organizations with Medicare. With the Medicare Pioneer ACO system, there is risk-sharing. We have several new global payment contracts where the providers will be fully at risk for thousands of patients. [Leslie, I will link the bundled and global payments terms to definitions within our website].

Reliant will also be at risk for the behavioral health services for certain patient populations.

5. Are you all on salary?

Yes.

6. How does Reliant fund neuropsychological services if there are no neuropsychologists on staff?

If a patient is in a contract, and they need neuropsychological services, Reliant physicians will send them to see a neuropsychologist who is not part of the Reliant organization. Because of quality and cost issues, physicians are looking for neuropsychologists who offer quality, value and good communication. They want to see a high quality assessment, that is timely, with a well written report.

7. Do you have any advice for neuropsychologists who are out in the community. How can they increase the likelihood that they will be that neuropsychologist the large health organizations refer to?

The key thing is for community neuropsychologists to go and speak with the large medical groups. A good place to start would be with the chief of neurology, or the chief of primary care. When the administrators make financial decisions about where to send part of their global payments out of the organization, they will start by asking these chiefs, “Who do you know who does a good job as a neuropsychologist?”

The administrators involved in the decisions are typically our Chief Medical Officer, the Director of Utilization and the Medical Director of Quality should also ask to speak with them.

8. Do you have any tips for neuropsychologists when speaking to administrators within medical organizations? This is not part of our typical skill set!

Yes. First, show a willingness to help the administrators with how you might provide quality assessments for a good value. How might you work with larger populations? Demonstrate that you can be flexible with your assessment techniques for some screening, some full batteries.

Administrators and physicians within the larger medical homes are also very interested in you being a good communicator. Are you writing timely, targeted reports? Are you addressing the type of information they need to do their clinical jobs?

As a neuropsychologist, if you show some understanding of their dilemma, treating large populations of patients, with both high quality, and high value services, then they will see you as an ally.

Dr. Lanca is engaged in an innovative program of bringing neuropsychological assessments directly into the primary care medical home clinics at Cambridge Health Alliance.

1. You have an innovative approach to embedding neuropsychological services in primary care settings. Can you tell us about it?

Since Cambridge Health Alliance (CHA) has
been transforming into an accountable care organization (ACO), it has become
increasingly important to forge closer affiliations with our primary care providers. So we expanded our neuropsychology
services to include cognitive screening at one of CHA primary care clinics,
while maintaining our outpatient neuropsychology clinic for comprehensive and
“typical” neuropsychological assessments.
These one-hour long cognitive screens in primary care with very brief
write-ups are focused on providing diagnostic screening of AD/HD and dementia
versus pseudo-dementia. Currently,
we are developing a third cognitive screening protocol for high utilizer
complex patients to determine cognitive deficits that can impede medication
adherence and treatment compliance.

2. How have physician colleagues at CHA responded to the changes?

The clinic’s physicians have welcomed
our presence and referrals have been nonstop. There are even greater opportunities for growth. Many of CHA’s primary care clinics such
as the one where we are based are functioning as medical homes so that primary
care physicians and other physicians are accustomed to working on
multi-disciplinary teams and have a highly developed system of coordination of
care. Neuropsychological input to
a patient’s cognitive functioning is vital to physicians who sometimes struggle
to understand how to best treat a patient and know what expectations can be
made of that patient to follow treatment.
We have also had increased communication with the clinic’s clinical
pharmacist who benefits from our cognitive screens of patients who are having
difficulty with medication compliance.
Physicians have also appreciated that, as neuropsychologists we are well
versed in screening for both psychiatric conditions and cognitive conditions. Although we have not yet done screening
just for mood disorders, we sometimes diagnose depression and other mood
disorders from referrals for AD/HD and dementia. Mood disorder screening can be another way for
neuropsychologists to function in primary care. We have forged a close working relationship with the team
psychiatrist who also appreciates our cognitive screening as a means to
streamline her referrals and to increase understanding of patients. Overall, our neuropsychology presence
has resulted in a positive recalibration of other team physicians’ duties (i.e.,
primary care, clinical pharmacist, and psychiatrist) to enhance overall patient
treatment and increase the efficiency of their work.

3. Can you tell us about the process of moving your services into primary care? Who did you approach? Was it a tough sell?

The overall process of moving to primary
care was supportive and encouraging.
I first approached the Chief of Psychology and then the Chief of the
Psychiatry department, where our outpatient neuropsychology clinic is
based. To contextualize the
process, our psychiatry department had been apprised of the hospital’s
transformation to an ACO for at least a year prior to my proposal for cognitive
screening. We had numerous
psychology faculty meetings to discuss the potential impact of this transformation
to our work – much of it unknown.
Several Psychiatry-Medicine Grand Rounds were dedicated to staff education
ACO and Primary Care Medical Home (PCMH) models, and numerous psychiatry and
psychology faculty meetings prepared us for inevitable shifts in our work. We were asked to accept the possibility
of change in our usual ways of doing things, and encouraged to think
innovatively about how to shift our practice to fit with an ACO and PCMH model
of care. So when I approached our
departmental chiefs, there was strong support for my proposal to do cognitive
screening. I then approached the Medical
Director of the primary care clinic who expressed interest and recognized the
value to cognitive screening. The
Medical Director and I then proceeded with a series of planning and strategic
meetings for six months, before we embarked our neuropsychology work.

4. How does the billing work in your new embedded model? Are you dealing with global or bundled payments yet?

Because CHA has not completed the
transformation process to an ACO model, we do not yet have global or bundled
payments. We use our typical CPT
codes.

5. You are also the Director of the Neuropsychology Postdoctoral Training Program. What advice do you have for training directors to help students make the transition to practice in these uncertain times?

Neuropsychology will
undoubtedly go through its own transformation as the large majority of
hospitals and medical clinics in the US are now poised to convert to ACOs. Primary care and preventative medicine
will become more prominent in our health care system. My advice for training directors is to teach students to be
versatile and adaptive. This
translates to giving students a range of training experiences working with
different patient populations and across various settings. Training students to write
different kinds of reports – from cognitive screen brief-write ups to
comprehensive neuropsychological evaluations broadens their skill set. Having students interface with patients
at every level of an evaluation is also important. We teach our postdoctoral fellows how to provide feedback to
patients, an important skill to develop as our neuropsychology professional referral
base widens from its neurology and psychiatry roots to other specialties that
are not well versed in neuropsychology.
These professional colleagues depend on us to share test findings with
patients. One very new skill for
our postdoctoral fellows working in primary care, is to learn how to provide
feedback to patients almost instantaneously (after consultation with the staff
neuropsychologist). As
neuropsychologists, we are accustomed to scoring and interpreting reports and
cogitating on its findings. We
provide feedback to patients when we are ready. Our medical colleagues are trained to “think on their feet”
and respond to patients at the end of a visit. This can be an uncomfortable paradigm shift in our fellows’
neuropsychology training, but an important one that again, increases their
versatility. Finally, if there are
opportunities to give postdoctoral fellows some experience working with primary
care physicians either as embedded clinicians in a primary care clinic or
through outsourced referrals, I would highly recommend it. The greater the connection that
neuropsychologists can make with primary care physician colleagues, the more
viable our profession will be in the future. We need to be considered as a
first-line referral source for cognitive testing by primary care physicians,
not as secondary and tertiary referral sources.

Dr. Duquette made a decision to join Cornerstone Healthcare as a staff neuropsychologist following his fellowship. The large, multi-specialty medical group is an early adopter in healthcare reform, and was chosen as a Medicare ACO Pioneer Pilot. Dr. Duquette shares his front seat view of healthcare reform from the perspective of a staff member in a large, private healthcare system.

Can you tell us about
Cornerstone Healthcare?

Cornerstone was formed in the mid 1990s and is now a large
group of over 300 physicians and specialists that serves a 40-50 mile
geographic radius. There are a lot
of academic medical centers in this region of North Carolina, and Cornerstone
made a name for themselves offering quality care while reducing costs. In the last year and a half,
Cornerstone has developed partnerships with commercial payers and is a Medicare
ACO Pioneer Pilot organization.

What is your role with
Cornerstone?

I am one of 4 neuropsychologists in the organization, and
the only pediatric neuropsychologist.

How is the practice of
neuropsychology different at Cornerstone than within a typical medical or group
practice setting?

Cornerstone is in the process of “embedding” psychologists
and neuropsychologists within certain clinics. Several of the neuropsychologists who focus on geriatrics
are centrally involved in a Memory and Aging Care Clinic that collaborates with
Neurology. There is also a clinical
health psychologist who works part-time in the Heart Failure Clinic, in
addition to a full time psychologist who is the director of psycho-social
services within Oncology. There
are also three psychologists who are working in primary care or pediatrics
offices for at least part of their work weeks.

As the only pediatric neuropsychologist, I continue to get
referrals from a variety of clinics, including pediatrics, local schools, and
sports concussion.

How does billing work
for neuropsychologists?

We all share a billing service. We all get base salaries, and there is an incentive program
based on productivity and patient satisfaction. Some patients are in the process of being covered under
global or bundled payments, but the vast majority are still fee for
service. There is a population of
high medical utilizers: patients who are hypertensive, obese, in their 50s and
60s and above. That clinic is
looking toward a global payment situation. Neuropsychology has not yet had
experience with the global or bundled payments yet.

What is the biggest
change you have seen with health care reform in your work as a
neuropsychologist?

The biggest structural changes are the neuropsychologists
who are being embedded within clinics.

My report style has also changed a lot from the types of
reports I was writing as a post doc.
Cornerstone has been completely electronic with medical records for the
past 7 years.
When I finish an
assessment, I send a 1-paragraph summary to the referring physician through the
Electronic Medical Record. This
happens within 24 hours. I will
then dictate a report into Microsoft Word, and upload that file into the
EMR. Schools typically get a more
traditional report but I often send a brief summary ahead of time too. These brief communications are written
in chunks and are later pieced together for the 6-8 page final report. Some of this was based on recent
surveys conducted by AACN on what referral sources value most in our
reports. For example, the
pediatrician does not need highly detailed educational strategies. They are more interested in whether the
child is a good medication candidate.